Postpartum Hemorrhage Risk due to Prolonged Pitocin or High Dose of Pitocin Exposure

Abstract Objective This study aimed to evaluate the performance of the California Maternal Quality Care Collaborative (CMQCC) admission risk criteria for stratifying postpartum hemorrhage risk in a large obstetrics population. Study Design Using detailed electronic health record data, we classified 261,964 delivery hospitalizations from Kaiser Permanente Northern California hospitals between 2010 and 2017 into high-, medium-, and low-risk groups based on CMQCC criteria. We used logistic regression to assess associations between CMQCC risk groups and postpartum hemorrhage using two different postpartum hemorrhage definitions, standard postpartum hemorrhage (blood loss ≥1,000 mL) and severe postpartum hemorrhage (based on transfusion, laboratory, and blood loss data). Among the low-risk group, we also evaluated associations between additional present-on-admission factors and severe postpartum hemorrhage. Results Using the standard definition, postpartum hemorrhage occurred in approximately 5% of hospitalizations (n = 13,479), with a rate of 3.2, 10.5, and 10.2% in the low-, medium-, and high-risk groups. Severe postpartum hemorrhage occurred in 824 hospitalizations (0.3%), with a rate of 0.2, 0.5, and 1.3% in the low-, medium-, and high-risk groups. For either definition, the odds of postpartum hemorrhage were significantly higher in medium- and high-risk groups compared with the low-risk group. Over 40% of postpartum hemorrhages occurred in hospitalizations that were classified as low risk. Among the low-risk group, risk factors including hypertension and diabetes were associated with higher odds of severe postpartum hemorrhage. Conclusion We found that the CMQCC admission risk assessment criteria stratified women by increasing rates of severe postpartum hemorrhage in our sample, which enables early preparation for many postpartum hemorrhages. However, the CMQCC risk factors missed a substantial proportion of postpartum hemorrhages. Efforts to improve postpartum hemorrhage risk assessment using present-on-admission risk factors should consider inclusion of other nonobstetrical factors.

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MON-256 A Late-Onset Case of Sheehan’s Syndrome Presenting as Life Threatening Adrenal Insufficiency

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.1392 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Salman Zahoor Bhat ◽

Itivrita Goyal ◽

Manav Batra

Keyword(s):

Cortisol Level ◽

Postpartum Hemorrhage ◽

Late Onset ◽

Adrenal Crisis ◽

High Dose ◽

Sheehan’S Syndrome ◽

Number Of Patients ◽

Patient Reported ◽

Life Threatening ◽

Sheehan's Syndrome

Abstract OBJECTIVE Sheehan’s syndrome or postpartum pituitary necrosis, is an important but rare cause of hypopituitarism, caused due to severe postpartum hemorrhage. Seen more commonly in the developing world, it is less common in developed countries due to advanced obstetric practices. It can present acutely but more frequently has an insidious course (onset 10-20 years later) with variable hormonal deficiencies. Here, we report a late-onset case of Sheehan’s syndrome, 24 years after the incident event, presenting as life threatening adrenal failure. CASE PRESENTATION A 48-year-old female with no significant past medical history was admitted to the hospital after being found unresponsive at home. She had not seen a physician for many years. She complained of weakness and lethargy for a week and recently established care with a primary care physician. The patient was severely hypotensive in the emergency department and had an elevated temperature of 101°F. Physical examination showed no significant abnormalities. CBC and metabolic panel were not significantly altered. CSF analysis and CSF/blood cultures were negative for any infection. TSH was 4.29 mIU/mL (0.27-4.20) but the total and free T4 (fT4) were severely low at 1.1 mcg/mL (4.6-12) and 0.24 ng/dL (0.93-1.70) respectively. On further questioning, patient reported severe postpartum hemorrhage 24 years ago, needing multiple units of blood transfusion. This was followed by inability to lactate and menstruate but was never worked up as she had not seen any physician all these years. Pituitary hormonal panel was obtained, demonstrating multiple hormonal deficiencies with fT4 severely low at 0.24 ng/dL, ACTH of 2.6 pg/mL (7.2-63.3), prolactin (PRL) 1 ng/mL (4.8-23.3) and insulin like growth factor-1 (IGF-1) low at 10 ng/mL (56-194). Cortisol level was elevated in the hospital due to administration of high dose IV steroids but a morning cortisol level obtained 1 week prior by her primary was 1.5 mcg/dL (10-20). Estradiol levels were low with FSH and LH levels inappropriately normal. MRI of the pituitary was obtained which showed an empty sella turcica. Patient was diagnosed as late-onset Sheehan’s syndrome. She was started on hormone replacement with hydrocortisone followed by levothyroxine and had marked improvement in her symptoms. She continues to do well. CONCLUSION Our patient presented late due to lack of medical care and awareness. A great number of patients with Sheehan’s diseasae go undiagnosed due to subtle clinical presentations, thus delaying treatment. It is imperative to diagnose this condition timely with appropriate obstetric/gynecological history and clinical suspicion to avoid late manifestations of the disease, especially adrenal crisis. Patients at risk need long term follow-up. Early treatment is necessary to improve quality of life and reduce morbidity and mortality associated with this condition.

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The risk of postpartum hemorrhage in women using high dose of low-molecular-weight heparins during pregnancy

Thrombosis Research ◽

10.1016/j.thromres.2012.03.007 ◽

2012 ◽

Vol 130 (3) ◽

pp. 334-338 ◽

Cited By ~ 32

Author(s):

H. Marieke Knol ◽

Lejan Schultinge ◽

Nic J.G.M. Veeger ◽

Hanneke C. Kluin-Nelemans ◽

Jan J.H.M. Erwich ◽

...

Keyword(s):

Molecular Weight ◽

Postpartum Hemorrhage ◽

Low Molecular Weight ◽

High Dose ◽

Low Molecular Weight Heparins

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1092: Correlation of postpartum hemorrhage risk stratification with calculated blood loss greater than 1000 milliliters

American Journal of Obstetrics and Gynecology ◽

10.1016/j.ajog.2019.11.1104 ◽

2020 ◽

Vol 222 (1) ◽

pp. S673

Author(s):

Tina Chu ◽

Aldeboran N. Rodriguez ◽

Whitney Kleinmann ◽

Shivani Patel ◽

Robyn Horsager ◽

...

Keyword(s):

Blood Loss ◽

Risk Stratification ◽

Postpartum Hemorrhage ◽

Hemorrhage Risk

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Implementation of a Postpartum Hemorrhage Safety Bundle at an Urban Safety-Net Hospital

American Journal of Perinatology Reports ◽

10.1055/s-0040-1714713 ◽

2020 ◽

Vol 10 (03) ◽

pp. e255-e261

Author(s):

Naima T. Joseph ◽

Nikkia H. Worrell ◽

Janice Collins ◽

Melanie Schmidt ◽

Grace Sobers ◽

...

Keyword(s):

Risk Assessment ◽

Program Implementation ◽

Postpartum Hemorrhage ◽

Monitoring And Evaluation ◽

Safety Net ◽

Primary Objective ◽

Case Review ◽

Safety Net Hospital ◽

Urban Safety ◽

Hemorrhage Risk

Abstract Background Postpartum hemorrhage (PPH) is a leading cause of preventable maternal morbidity and mortality. Standardized response to obstetric hemorrhage is associated with significant improvement in maternal outcomes, yet implementation can be challenging. Objective The primary objective is to describe the methodology for program implementation of the Alliance for Innovation on Maternal Health Safety Bundle on PPH at an urban safety-net hospital. Methods Over an 18-month period, interventions geared toward (1) risk assessment and stratification, (2) hemorrhage identification and management, (3) team communication and simulation, and (4) debriefs and case review were implemented. Hemorrhage risk assessment stratification rates were tracked overtime as an early measure of bundle compliance. Results Hemorrhage risk assessment stratification rates improved to >90% during bundle implementation. Conclusion Keys to implementation included multidisciplinary stakeholder commitment, stepwise and iterative approach, and parallel systems for monitoring and evaluation Implementation of a PPH safety bundle is feasible in a resource-constrained setting.

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Factors affecting the prevention of postpartum hemorrhage in Low- and Middle-Income Countries: A scoping review of the literature

Journal of Nursing Education and Practice ◽

10.5430/jnep.v11n1p66 ◽

2020 ◽

Vol 11 (1) ◽

pp. 66

Author(s):

Oliva Bazirete ◽

Manassé Nzayirambaho ◽

Marie Chantal Uwimana ◽

Aline Umubyeyi ◽

Evans Marilyn

Keyword(s):

Risk Factors ◽

Scoping Review ◽

Postpartum Hemorrhage ◽

Middle Income ◽

Factors Affecting ◽

Factors Associated ◽

Middle Income Countries ◽

Hemorrhage Risk ◽

Childbearing Women ◽

Low And Middle Income

Background and objectives: Postpartum hemorrhage is an important cause of maternal mortality worldwide. A host of literature highlights the difficulty in predicting which women will experience Postpartum hemorrhage. The present study aims at describing the research output on factors affecting the prevention of Postpartum hemorrhage in Low- and Middle- Income Countries.Methods: A total of 24 published research articles and 2 papers from grey literature published between 2010 and 2019 were retrieved from PubMed, Scopus, CINAHL and Nursing and Allied Health Database (ProQuest). Data were extracted based on main study features and the findings were described narratively. Arksey and O’Malley’s framework for scoping studies was used in this review.Results: Findings from the literature from Low- and Middle- Income Countries are grouped into three themes: Knowledge and understanding about the prevention of Postpartum hemorrhage; Postpartum hemorrhage risk factors among childbearing women; and use of prophylactic uterotonic drugs for PPH prevention and related policies. The majority of studies investigate pharmacological interventions for PPH prevention, while few address the early assessment of risk factors associated with Postpartum hemorrhage for proactive prevention.Conclusions: The present study suggests that assessing risk factors associated with PPH would be a practical method for early identification of clients at high-risk for developing Postpartum hemorrhage. The present scoping review highlights the paucity of research considering Postpartum hemorrhage risk factors in low- and middle- income countries, particularly in Rwanda. Further qualitative research on the perceptions of health care workers and beneficiaries about Postpartum hemorrhage risk factors is warranted, to enable the development of a tool to assess risk factors associated to Postpartum hemorrhage among childbearing women in Low- and Middle- Income Countries.

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